Provider Demographics
NPI:1457393712
Name:TIEFENBRUNN, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:TIEFENBRUNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 S SERVICE RD W STE 10
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2306
Mailing Address - Country:US
Mailing Address - Phone:573-468-4455
Mailing Address - Fax:
Practice Address - Street 1:1326 S SERVICE RD W STE 10
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2306
Practice Address - Country:US
Practice Address - Phone:573-468-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203922505Medicaid
080140048OtherRAILROAD MEDICARE
MO1457393712Medicaid
014012943Medicare ID - Type Unspecified
080140048OtherRAILROAD MEDICARE
G30863Medicare UPIN